The resident, who has atrial fibrillation and a history of pulmonary embolus, had their Eliquis discontinued on July 2 for a surgical procedure. The medication was not restarted until October 1, creating a 91-day gap in anticoagulant therapy that went undetected through three separate pharmacy reviews.
Eliquis prevents blood clots in patients with atrial fibrillation, a heart rhythm disorder that significantly increases stroke risk. The medication is also prescribed for patients with a history of pulmonary embolus, a potentially fatal condition where blood clots travel to the lungs.
The resident had been taking Eliquis 5 milligrams every 12 hours since March 19. Physician orders show the medication was discontinued on July 2, likely in preparation for surgery, but no order was written to resume the blood thinner afterward.
The consultant pharmacist completed reviews on July 30, August 25, and September 24. None of these reviews flagged the missing anticoagulant or recommended restarting Eliquis therapy. The medication remained off the resident's active medication list for August and September.
On October 1, a physician finally ordered Eliquis to be restarted, this time at double the previous dose: two 5-milligram tablets every 12 hours for a total of 10 milligrams daily.
When inspectors interviewed the consultant pharmacist by phone on October 23, he acknowledged the oversight. He stated he had reviewed the nurse practitioner and medical director's notes along with laboratory results during his July review. "It was an oversight that the Eliquis was not included on his July 2025 pharmacy review," according to the inspection report.
The pharmacist told inspectors he knew Eliquis had been stopped by the physician and speculated it "might have been stopped because of bleeding after the procedure or other reasons." However, he could not remember specific details about why the medication was discontinued or why it was not restarted.
Federal regulations require consultant pharmacists to conduct monthly drug regimen reviews that include examining medical charts and following established policies for reporting irregularities. The reviews are designed to catch exactly these types of medication gaps that could harm residents.
The facility's medical director, interviewed the same day, agreed the monthly pharmacy reviews should have identified the problem. She stated the reviews "should have caught the Eliquis was not restarted and brought it to her attention."
The administrator and director of nursing, interviewed together that afternoon, acknowledged that "the Eliquis medication should have been reviewed and captured on the pharmacy reviews."
The three-month gap represents a significant lapse in care for a resident whose medical conditions require continuous anticoagulation. Patients with atrial fibrillation face a five-fold increase in stroke risk without proper blood thinning medication. Those with a history of pulmonary embolus remain at elevated risk for recurrent blood clots.
While the inspection classified this as causing "minimal harm or potential for actual harm," the failure illustrates how medication oversight systems can break down even with multiple safeguards in place. The consultant pharmacist conducted three separate reviews over the period when the blood thinner was missing, each representing a missed opportunity to identify the gap.
The case also highlights the critical importance of post-surgical medication reconciliation. When medications are stopped for procedures, clear protocols should ensure they are appropriately restarted when medically indicated.
The resident's Eliquis dose was doubled when finally restarted in October, suggesting the physician recognized the need for more aggressive anticoagulation after the prolonged interruption. The higher dose may reflect an attempt to quickly re-establish therapeutic blood levels or address increased clotting risk that developed during the gap.
This violation affected one of three residents reviewed by inspectors for unnecessary medications, suggesting broader concerns about medication management at the facility may warrant continued scrutiny.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for White Oak Manor - Charlotte from 2025-10-27 including all violations, facility responses, and corrective action plans.